NHS England
NHS / Health Body
Action Taken
NHS England acknowledges concerns about menopausal care and highlights increased awareness and demand. They describe training programmes, awareness sessions and e-learning packages that have been launched, some since Anne's death, to improve resources for healthcare practitioners. (AI summary)
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Dear Ms Marsh, Re: Regulation 28 Report to Prevent Future Deaths – Jacqueline Anne Potter who died on 5 December 2022.
Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 24 April 2025 concerning the death of Jacqueline Anne Potter (known as Anne) on 5 December
2022. In advance of responding to the specific concerns raised in your Report, I would like to express my deep condolences to Anne’s family and loved ones. NHS England are keen to assure the family and the Coroner that the concerns raised about Anne’s care have been listened to and reflected upon.
Your Report raises concerns around the importance of providing families with the tools and knowledge to assist in safeguarding loved ones with mental health illness when they are in the community, along with the perceived lack of importance given to menopausal care available to women on the NHS. This response focuses on the issue of menopausal care and the areas which are within NHS England’s remit.
Menopause and perimenopause are increasingly recognised as a time that can, but not always, cause considerable distress to a woman. We have seen a rapid increase in demand for menopause care in recent years, as a result of more media attention. Whilst women receive high quality NHS menopause care in many areas, it is also acknowledged that variation across services locally / regionally remains.
Many women who are experiencing menopause symptoms attend their GP for help and advice. Menopause care is part of the core curriculum for General Practice, which is the basis of training for all GPs in order to qualify. The GP curriculum: Clinical topic guides highlights menopause care as a requirement, which has more recently been updated to emphasise a changing landscape in the management of menopause, the need to be aware of the mental distress experienced by some women in this period, and being up to date on all evidence-based treatment options. Improving awareness of mental health symptoms during menopause will help GPs to consider this as one of the causes, and to provide appropriate advice and treatment options.
Practice nurses also have a significant role in menopause care and are often the first port of call for someone experiencing difficulties, or who may have the opportunity to proactively enquire about the menopause. In 2024, NHS England published specific National Medical Director NHS England Wellington House 133-155 Waterloo Road London SE1 8UG
5 June 2025
Menopause Educational resources to enhance learning for practice nurses. As the demand for menopause care has risen in recent years, some GPs and practice nurses seek further qualifications in more specialist care such as the training programme offered by the British Menopause Society. Many GP practices will now have at least one member of staff who is able to offer more complex menopause care. Whilst this may not be available at every GP practice in England, in many practices, and increasingly, there is a lead person who is able to offer this.
There is often variation between GPs and practices in the level of complexity of care they are able to provide. Women’s Health Hubs were piloted in 2023/2024, seeking to reduce the variations in reproductive healthcare which women reported receiving. They provide the option for women to be referred to more specialist reproductive health care (including menopause care) if the GP needs further advice. Women’s Health Hubs have yet to achieve full coverage, but have the potential to fill the gap in care where this is more complex. NHS England is working closely with its regions and Integrated Care Boards (ICBs) to ensure that every woman can access good menopause care wherever they are in the country.
Working in a multidisciplinary team (MDT) alongside mental health practitioners, GPs and menopause specialists are an essential part of good menopause care and are a key element of a future neighbourhood model of care, which will help to ensure that a range of professionals are involved in the most complex cases.
A toolkit that supports local areas to provide menopause information events and group consultations is under development to improve access and also to provide a forum for learning for other healthcare professionals. NHS England is working on menopause workforce support packages for employees and employers and developing a range of tools to upskill, including two e-learning packages (Menopause Awareness – elearning for healthcare and Menopause and people professionals eLearning for healthcare), decision support tools and a self-care factsheet to empower women to understand and self-manage their perimenopause and menopause symptoms, and to point them towards further sources of credible information.
Whilst I acknowledge the Coroner’s comments regarding menopause resources and use of the NHS website, appreciating that online resources do not compare to patient consultations with a medically qualified professional, the menopause page on the NHS website has also recently been updated to include the most up-to-date, evidence- based information on menopause. This includes information about symptoms, where to seek treatment, lifestyle changes that may help with symptoms, and signposting to other helpful resources.
NHS England’s StatMand Reform programme is leading work to optimise, rationalise and redesign statutory and mandatory training during 2025/26 in partnership with the Department of Health and Social Care, Health Services Safety Investigations Body (HSSIB) and NHS Resolution. There are three levels of mandatory training:
1. Nationally mandated – typically associated with statutory obligations, largely summarised in the Core Skills Training Framework or in other policy. This includes training on subjects such as the General Data Protection Regulation (GDPR) and handling of sharp objects, amongst many other things. It is this
nationally mandated training that NHS England is currently reforming (as stated above).
2. Locally mandated – each employing organisation will determine what should be mandated to all or most of their staff to meet priorities and patient needs. This training varies between organisations, with some similarities.
3. Profession or role specific mandated – this is determined by the respective professions and royal colleges and will form part of standards for professional development and curriculum for future trainees.
The potential for menopause training to be mandated has been raised as part of the NHS England reform work, which is yet to conclude it’s work. It is likely that menopause training would most appropriately fit at a professional/role specific level and we expect to engage with profession leads and royal colleges in due course to consider this, alongside a number of similar topics, once the reform of the nationally mandated training has concluded.
In addition, the Technology Enhanced Learning (Workforce, Education and Training directorate (WTE)) team at NHS England manage and host training on the e-lfh hub and Learning Hub platforms. National WTE colleagues work directly with subject matter experts within professional bodies and the NHS to design, develop and deliver e-learning training sessions/modules. They also work within defined medical training curriculums, as defined by the professional bodies and NHS England, and design and develop relevant e-learning sessions.
Menopause related online training available at the time of Anne’s death in 2022 included training within the General Practice 2012 Curriculum (e-GP) programme. The e-GP Programme provides a programme of e-learning modules covering the Royal College of General Practitioners (RCGP) curriculum. The programme has been designed to:
1. Facilitate the delivery of the RCGP curriculum at national, local and individual learner levels.
2. Provide relevant, comprehensive and accessible learning content for GPs working in the UK.
3. Embody adult learning principles and support a blended approach to learning.
4. Support postgraduate doctors in training to become GPs.
5. Support GPs in Continual Professional Development (CPD) and revalidation.
The e-learning modules which are part of this programme include ‘What is the Menopause’, ‘Managing the Menopause’, ‘Hormone Replacement Therapy (HRT)’ and ‘Premature Menopause’.
Other menopause related online training includes:
• The Sexual and Reproductive Health (E-SRH) programme, developed in partnership with the Faculty of Sexual and Reproductive Healthcare (FSRH). The programme supports a range of healthcare professionals and compliments the redesigned FSRH Diploma (DFSRH) as well as other FSRH qualifications.
In recent years, the NHS England National Menopause programme has also launched a series of awareness sessions, including the ‘Menopause awareness’ and ‘Menopause and people professionals’ e-learning packages referenced earlier on in this response, as well as e-learning on ‘Menopause and occupational health’.
NHS England notes that some of the above training became available following Anne’s death, but hopes that this provides some reassurance to the Coroner and Anne’s family that additional resources have since been made available to healthcare practitioners and further improvements have been made to menopause care, training and resources.
Anne’s tragic death has highlighted important gaps in the care of women experiencing perimenopause or menopause and the potential for improvements. NHS England will continue to promote high quality and equitable coverage of menopause care for all.
I would also like to provide further assurances on the national NHS England work taking place around the Reports to Prevent Future Deaths. All reports received are discussed by the Regulation 28 Working Group, comprising Regional Medical Directors, and other clinical and quality colleagues from across the regions. This ensures that key learnings and insights around events, such as the sad death of Anne, are shared across the NHS at both a national and regional level and helps us to pay close attention to any emerging trends that may require further review and action.
Thank you for bringing these important patient safety issues to my attention and please do not hesitate to contact me should you need any further information.
Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 24 April 2025 concerning the death of Jacqueline Anne Potter (known as Anne) on 5 December
2022. In advance of responding to the specific concerns raised in your Report, I would like to express my deep condolences to Anne’s family and loved ones. NHS England are keen to assure the family and the Coroner that the concerns raised about Anne’s care have been listened to and reflected upon.
Your Report raises concerns around the importance of providing families with the tools and knowledge to assist in safeguarding loved ones with mental health illness when they are in the community, along with the perceived lack of importance given to menopausal care available to women on the NHS. This response focuses on the issue of menopausal care and the areas which are within NHS England’s remit.
Menopause and perimenopause are increasingly recognised as a time that can, but not always, cause considerable distress to a woman. We have seen a rapid increase in demand for menopause care in recent years, as a result of more media attention. Whilst women receive high quality NHS menopause care in many areas, it is also acknowledged that variation across services locally / regionally remains.
Many women who are experiencing menopause symptoms attend their GP for help and advice. Menopause care is part of the core curriculum for General Practice, which is the basis of training for all GPs in order to qualify. The GP curriculum: Clinical topic guides highlights menopause care as a requirement, which has more recently been updated to emphasise a changing landscape in the management of menopause, the need to be aware of the mental distress experienced by some women in this period, and being up to date on all evidence-based treatment options. Improving awareness of mental health symptoms during menopause will help GPs to consider this as one of the causes, and to provide appropriate advice and treatment options.
Practice nurses also have a significant role in menopause care and are often the first port of call for someone experiencing difficulties, or who may have the opportunity to proactively enquire about the menopause. In 2024, NHS England published specific National Medical Director NHS England Wellington House 133-155 Waterloo Road London SE1 8UG
5 June 2025
Menopause Educational resources to enhance learning for practice nurses. As the demand for menopause care has risen in recent years, some GPs and practice nurses seek further qualifications in more specialist care such as the training programme offered by the British Menopause Society. Many GP practices will now have at least one member of staff who is able to offer more complex menopause care. Whilst this may not be available at every GP practice in England, in many practices, and increasingly, there is a lead person who is able to offer this.
There is often variation between GPs and practices in the level of complexity of care they are able to provide. Women’s Health Hubs were piloted in 2023/2024, seeking to reduce the variations in reproductive healthcare which women reported receiving. They provide the option for women to be referred to more specialist reproductive health care (including menopause care) if the GP needs further advice. Women’s Health Hubs have yet to achieve full coverage, but have the potential to fill the gap in care where this is more complex. NHS England is working closely with its regions and Integrated Care Boards (ICBs) to ensure that every woman can access good menopause care wherever they are in the country.
Working in a multidisciplinary team (MDT) alongside mental health practitioners, GPs and menopause specialists are an essential part of good menopause care and are a key element of a future neighbourhood model of care, which will help to ensure that a range of professionals are involved in the most complex cases.
A toolkit that supports local areas to provide menopause information events and group consultations is under development to improve access and also to provide a forum for learning for other healthcare professionals. NHS England is working on menopause workforce support packages for employees and employers and developing a range of tools to upskill, including two e-learning packages (Menopause Awareness – elearning for healthcare and Menopause and people professionals eLearning for healthcare), decision support tools and a self-care factsheet to empower women to understand and self-manage their perimenopause and menopause symptoms, and to point them towards further sources of credible information.
Whilst I acknowledge the Coroner’s comments regarding menopause resources and use of the NHS website, appreciating that online resources do not compare to patient consultations with a medically qualified professional, the menopause page on the NHS website has also recently been updated to include the most up-to-date, evidence- based information on menopause. This includes information about symptoms, where to seek treatment, lifestyle changes that may help with symptoms, and signposting to other helpful resources.
NHS England’s StatMand Reform programme is leading work to optimise, rationalise and redesign statutory and mandatory training during 2025/26 in partnership with the Department of Health and Social Care, Health Services Safety Investigations Body (HSSIB) and NHS Resolution. There are three levels of mandatory training:
1. Nationally mandated – typically associated with statutory obligations, largely summarised in the Core Skills Training Framework or in other policy. This includes training on subjects such as the General Data Protection Regulation (GDPR) and handling of sharp objects, amongst many other things. It is this
nationally mandated training that NHS England is currently reforming (as stated above).
2. Locally mandated – each employing organisation will determine what should be mandated to all or most of their staff to meet priorities and patient needs. This training varies between organisations, with some similarities.
3. Profession or role specific mandated – this is determined by the respective professions and royal colleges and will form part of standards for professional development and curriculum for future trainees.
The potential for menopause training to be mandated has been raised as part of the NHS England reform work, which is yet to conclude it’s work. It is likely that menopause training would most appropriately fit at a professional/role specific level and we expect to engage with profession leads and royal colleges in due course to consider this, alongside a number of similar topics, once the reform of the nationally mandated training has concluded.
In addition, the Technology Enhanced Learning (Workforce, Education and Training directorate (WTE)) team at NHS England manage and host training on the e-lfh hub and Learning Hub platforms. National WTE colleagues work directly with subject matter experts within professional bodies and the NHS to design, develop and deliver e-learning training sessions/modules. They also work within defined medical training curriculums, as defined by the professional bodies and NHS England, and design and develop relevant e-learning sessions.
Menopause related online training available at the time of Anne’s death in 2022 included training within the General Practice 2012 Curriculum (e-GP) programme. The e-GP Programme provides a programme of e-learning modules covering the Royal College of General Practitioners (RCGP) curriculum. The programme has been designed to:
1. Facilitate the delivery of the RCGP curriculum at national, local and individual learner levels.
2. Provide relevant, comprehensive and accessible learning content for GPs working in the UK.
3. Embody adult learning principles and support a blended approach to learning.
4. Support postgraduate doctors in training to become GPs.
5. Support GPs in Continual Professional Development (CPD) and revalidation.
The e-learning modules which are part of this programme include ‘What is the Menopause’, ‘Managing the Menopause’, ‘Hormone Replacement Therapy (HRT)’ and ‘Premature Menopause’.
Other menopause related online training includes:
• The Sexual and Reproductive Health (E-SRH) programme, developed in partnership with the Faculty of Sexual and Reproductive Healthcare (FSRH). The programme supports a range of healthcare professionals and compliments the redesigned FSRH Diploma (DFSRH) as well as other FSRH qualifications.
In recent years, the NHS England National Menopause programme has also launched a series of awareness sessions, including the ‘Menopause awareness’ and ‘Menopause and people professionals’ e-learning packages referenced earlier on in this response, as well as e-learning on ‘Menopause and occupational health’.
NHS England notes that some of the above training became available following Anne’s death, but hopes that this provides some reassurance to the Coroner and Anne’s family that additional resources have since been made available to healthcare practitioners and further improvements have been made to menopause care, training and resources.
Anne’s tragic death has highlighted important gaps in the care of women experiencing perimenopause or menopause and the potential for improvements. NHS England will continue to promote high quality and equitable coverage of menopause care for all.
I would also like to provide further assurances on the national NHS England work taking place around the Reports to Prevent Future Deaths. All reports received are discussed by the Regulation 28 Working Group, comprising Regional Medical Directors, and other clinical and quality colleagues from across the regions. This ensures that key learnings and insights around events, such as the sad death of Anne, are shared across the NHS at both a national and regional level and helps us to pay close attention to any emerging trends that may require further review and action.
Thank you for bringing these important patient safety issues to my attention and please do not hesitate to contact me should you need any further information.